CLINICAL OBSTETRICS AND GYNECOLOGY Volume 00, Number 00, 000–000 Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved. First Trimester Abortion Care in Low and Middle-income Countries ANDREA HENKEL, MD, and KATE A. SHAW, MD, MS Department of Obstetrics and Gynecology, Division of Family Planning Services and Research, Stanford University, Stanford, California Abstract: Access to first trimester abortions has account for ~86% of all abortions.1 The increased significantly in the past few decades in low vast majority, nearly 90% of abortions, and middle-income countries. Manual vacuum aspi- ration is now standard of care for procedural abortion take place in the first trimester. Increased and postabortion care. Medication abortion has access to technology enabling earlier de- shifted abortions to being performed earlier in preg- tection of pregnancy and the rising access nancy and is becoming more widely available with to and use of medication abortion have new service delivery strategies to broaden access. shifted abortions to being performed ear- Widespread availability of misoprostol has made abortions induced outside of the formal medical sector lier in pregnancy. overall safer. In both legally restrictive and supportive In many LMICs, girls are attending environments, there is increased interested in self- school longer, more women are working managed abortions as part of a shift towards deme- outside of the home, and the age at first dicalizing abortion through task-sharing. marriage has increased. Consequently, Key words: abortion, first-trimester, manual vacuum aspirator, misoprostol, mifepristone, self-managed more women desire to delay childbearing and seek greater control over birth-spac- ing. In addition, desired family size has fallen dramatically; the increased desire for Introduction smaller families being most appreciable in Globally, an estimated 56.3 million abor- Asia, Europe, and Central America.2 tions occur each year; those occurring in Rates of unintended and mistimed preg- low-to-middle-income countries (LMICs) nancies have decreased with increasing access to and use of contraception, result- Correspondence: Kate Shaw, MD, MS, Department of ing in a decline in global abortion rates.3 Obstetrics and Gynecology, Division of Family Planning Services and Research, Stanford University, However, where access to contraception Stanford, CA. E-mail: [email protected] lags behind women’s changing fertility The authors declare that they have nothing to disclose. preferences, women may turn to abortion CLINICAL OBSTETRICS AND GYNECOLOGY / VOLUME 00 / NUMBER 00 / ’’ 2021 www.clinicalobgyn.com | 1 Copyright r 2021 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited. 2 Henkel and Shaw as a way of controlling their fertility. Similarly, after abortion was legalized Therefore, the incidence of abortions may in 2004 in Nepal, the number of women be most reflective of the level of unmet admitted for complications of unsafe need for contraception and contraceptive abortion and the severity of those com- effectiveness in a given geographic area. plications significantly declined; the total number of maternal deaths in Nepal also declined.8 International Abortion Policy Access may depend on what is practi- In the last 20 years, > 30 countries have cally available beyond what is legally amended their laws to expand access to available. The United States remains the safe and legal abortion services.4 How- single largest donor to family planning ever, that still leaves over 40% of women and reproductive health programs over- of reproductive-age living in a country seas.9 However, 2 long standing US pol- where abortion remains highly restricted. icies significantly limit access to abortion: Nearly all countries with the most highly the 1973 Helms amendment, which pro- restrictive laws are LMICs. While there hibits the use of US foreign assistance has been progress in legislatively liberal- funds to pay for the provision of abortion izing abortion access in many LMICs, El services, followed by the 1984 Mexico Salvador and Nicaragua are the notable City Policy, requiring foreign nongovern- exceptions and have taken steps to addi- mental organizations to certify that they tionally restrict abortion. will not perform or promote abortion as a The legislative environment in a coun- method of family planning as a condition try directly impacts the safety of abortion of receiving US funding. Both policies in that country. When legal access to have been rescinded and reinstated by abortion is restricted, women look to alternating administrations along parti- alternatives outside of the formal health san lines and has now been in effect for 19 care sector. Consequently, the prevalence of the past 34 years. of unsafe abortions increases when abor- Many organizations affected by this tion restrictions increase, from 1% of all policy also provide contraception. In an abortions being unsafe in countries with analysis of countries in sub-Saharan Afri- the least-restrictive laws to 31% in those in ca, the use of contraception declined by the most-restrictive laws.5 As restrictive 14% in countries with high-exposure to abortion laws tend to coincide with re- the Mexico City Policy compared with stricting access to modern contraception, those with low-exposure during periods the number of unintended pregnancies when the policy was in place.10 Conse- has increased in LMICs with the most quently, abortion rates increased by 40% restrictive abortion laws.6 As a result, in countries with high-exposure compared abortion rates are paradoxically highest with those countries with low-exposure. in the most legislatively restrictive By reducing these organizations’ ability countries. to supply modern contraceptives, the The impact of liberalizing abortion Mexico City Policy, ironically, increases laws on decreasing maternal mortality abortion rates. has been well characterized in the liter- ature. Six years after liberalizing its abor- tion laws, South Africa saw a 50% decrease in maternal mortality as rates Unsafe Abortion and of unsafe abortion fell; the number of Postabortion Care (PAC) hospitalizations and severity of postabor- Unsafe abortion remains a top 5 causes of tion complications fell markedly as well.7 maternal mortality with an estimated www.clinicalobgyn.com Copyright r 2021 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited. First Trimester Abortion Care in LMIC 3 47,000 deaths annually attributed to un- globally are unsafe—31% are less safe and safe abortion; nearly all occurring in 14% are least safe.5 Of the estimated 25 LMIC countries.11 A recent systematic million unsafe abortions each year, 97% analysis estimates that 8% of all maternal take place in LMICs. deaths are due to unsafe abortion.12 This Women and untrained providers use finding is lower than the previous assess- many types of traditional and nonmedical ments, either suggesting that maternal methods to end unintended pregnancies. mortality due to unsafe abortion is de- Past reports were rife with women insert- creasing or misclassification and under- ing foreign objects into the vagina or reporting are artificially lowering reports. cervix, liquids into the vagina, consuming There is significant geographic variation alcohol, detergent, bleach, acid, turpen- in proportion of maternal deaths tine, teas or pharmaceuticals, or inducing attributed unsafe abortions: 0.8% in east- trauma to the abdomen. Fortunately, ern Asia, 9.9% in Latin America and the women seeking to terminate a pregnancy Caribbean, and 9.6% in sub-Saharan are increasingly able to obtain misopros- Africa. tol to self-induce an abortion in response The World Health Organization to the WHO’s listing of misoprostol on (WHO) defines unsafe abortion as a the Essential Medication List in 2009.14 procedure for terminating a pregnancy As a result, unsafe abortions are now performed by persons lacking the neces- less unsafe because fewer occur by inva- sary skills or in an environment not in sive or toxic methods. However, women conformity with minimal medical stand- using misoprostol remain at risk of com- ards, or both.13 With recent changes in plications if they cannot get the necessary abortion provision and methods, a broad- information to use the method correctly. er, more nuanced conceptual framework PAC treatment rates have not declined has been proposed to update the WHO despite the increase in access to misopros- definition in 2017.5 According to this tol-only abortions.15 This may reflect a framework, abortions would fall into 1 combination of a relatively high first- of 3 categories: safe, less safe, and least trimester failure rate associated with a safe (with the latter 2 categories together misoprostol-only regimen, many women comprising unsafe abortions). An abor- are inadequately informed about what to tion is classified as safe if it takes place expect and seek care for what is an using a safe method and is done by an otherwise anticipated clinical course of appropriately trained provider (per WHO bleeding or cramping, and some providers guidelines above); less-safe abortions are specifically instruct women to go to facili- those that meet only one of the 2 criteria, ties for surgical aspiration soon after and least-safe abortions are those that bleeding starts.16 meet neither standard (Table 1). Using In 2012, almost 7 million women this definition, about 45% of abortions were treated for complications of unsafe